Enhanced Wavefront Refractions and Outcomes

Luminary
Insights
Enhanced Wavefront Refractions and Outcomes
PARTICIPANTS
Larry E. Patterson, MD
Mitchell A. Jackson, MD
Cynthia Matossian, MD
Joseph C. Noreika, MD
James J. Salz, MD
Jonathan D. Solomon, MD
Farrell “Toby” Tyson, MD
Highlights from a live symposium held during the 2013 meeting
of the American Academy of Ophthalmology in
New Orleans, LA.
Sponsored by
April 2014
Luminary Insights
Program Moderator
Enhanced
Refractions
and Outcomes
LarryWavefront
E. Patterson,
MD
Medical Director
Eye Centers of Tennessee in Crossville
Faculty
Mitchell A. Jackson, MD
Founder and Medical Director
Jacksoneye
Lake Villa, IL
Lumina
Cynthia Matossian, MD
Medical Director
Matossian Eye Associates
Hopewell, NJ
Joseph C. Noreika, MD
Senior Ophthalmologist
Excellence in Eyecare, Inc.
Medina, OH
James J. Salz, MD
Private practitioner
Laser Vision Medical Associates
Los Angeles
Clinical Professor of Ophthalmology
University of Southern California
Editorial Staff
EDITOR-IN-CHIEF, Ophthalmology Management: Larry E. Patterson, MD
EDITORIAL DIRECTOR, SPECIAL PROJECTS: Angela Jackson
EDITOR, SPECIAL PROJECTS: Leslie Goldberg
CONTRIBUTING EDITOR: Erin Murphy
Production
Jonathan D. Solomon, MD
Surgical and Refractive Director
Solomon Eye Physicians and Surgeons
Bowie, MD
PRODUCTION DIRECTOR: Sandra Kaden
PRODUCTION MANAGER: Bill Hallman
Editorial and Production Offices
321 Norristown Road, Suite 150, Ambler, PA 19002
Phone: (215) 628-6550
Business Staff Farrell “Toby” Tyson, MD
2
Medical Director, CEO
Cape Coral Eye Center
Florida Center in Cape Coral and
Tyson Eye in Fort Myers, FL
PRESIDENT: Thomas J. Wilson
EXECUTIVE VICE PRESIDENT AND PUBLISHER: Douglas A. Parry
PROMOTIONAL EVENTS MANAGER: Michelle Kieffer
Ophthalmology Management is published by PentaVision LLC.
Copyright 2014, PentaVision LLC. All Rights Reserved.
ary Insights
Enhanced Wavefront Refractions and Outcomes
Highlights from a live discussion held at the Bevolo
Lighting Company in New Orleans during the 2013
meeting of the American Academy of Ophthalmology
Larry E. Patterson, MD: A number of years have passed since the
introduction of wavefront technology. As pioneers in its development, what do
you feel have been the greatest advances and general applications of wavefront
in the past few years?
Mitchell A. Jackson, MD: New wavefront technologies are now able to
capture a large amount of diagnostic data in a short period of time, which
allows us to make more confident clinical decisions at a reasonable cost with
a profitable return. With challenges such as reduced reimbursements and
increased overhead costs, we need the improved outcomes, efficiencies and
profitability that new diagnostic systems provide.
Farrell “Toby” Tyson, MD: We experienced an explosion in lens technology,
but it was difficult to match each patient with the lens that would be of the
most benefit. Now we have the ability to quickly and efficiently analyze the
patient’s vision, looking at everything as a whole, so we can decide which lens
technology is best for that individual.
Cynthia Matossian, MD: Because patient expectations are high, it’s become
critical that we use wavefront technology to select and customize implants for
each patient. In addition, the maps help me educate patients and engage them
in the decision-making process.
Joseph C. Noreika, MD, MBA: We need to be almost perfect to meet the
expectations of today’s cataract patients. That’s where this technology really
shines. It gives us more data, so we can make better informed decisions.
Jonathan D. Solomon, MD: I think the most interesting aspect of wavefront
technology is that it allows us to look at a patient whose specific needs or
conditions are unclear, understand what’s going on in the eye and ultimately
help him achieve his visual goal.
James J. Salz, MD: Without wavefront technology, you can have patients with
20/20 results who are unhappy with their vision, and you don’t understand
why. Wavefront technology presents the aberrations in a graphic way, showing
us exactly why those patients are unhappy. It’s also a great way to teach
patients about their eyes and show them how surgery will address their
existing aberrations.
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Luminary Insights
Enhanced Wavefront Refractions and Outcomes
Getting a First Look
Dr. Patterson: What’s the first step you
take when evaluating a patient who will be
undergoing cataract surgery?
Dr. Jackson: I examine the ocular surface
•
“I can actually use our
EHR system
to show the
OPD- Scan III images.
With these images,
patients can see that
by correcting lenticular
astigmatism with
cataract removal, the
corneal astigmatism
will remain unless a
toric IOL is used.”
— Mitch Jackson, MD
for signs of dry eye and other potential
problems. I use the OPD-Scan III to obtain
a clear placido disk image. Astigmatism
is very important as well. I use several
advanced lens technologies such
as tear lab osmolarity to assess the
ocular surface, OCT imaging to assess
the macula preoperatively, and the
OPD-Scan III to assess corneal topography,
spherical aberration, and angle kappa
preoperatively. The OPD-Scan III system
allows me to see if the patient has corneal
astigmatism or lenticular astigmatism.
I can actually use our EHR system to
show the OPD-Scan III images. With
these images, patients can see that by
correcting lenticular astigmatism with
cataract removal, the corneal astigmatism
will remain unless a toric IOL is used.
For post-LASIK cataract patients,
the spherical aberration and coma help
me decide if I should choose an aspheric
lens or a negative spherical aberration
lens. Finally, I evaluate angle kappa to
determine if the patient should receive a
multifocal lens. The OPD-Scan III allows
me to capture all of these important
factors in seconds.
Understanding
Spherical Aberrations
Dr. Patterson: For years, we’ve been
implanting lenses without information
about spherical aberrations. Do they
really matter? In your practice, do you
match patients to IOLs based on their
corneal spherical aberrations?
Dr. Tyson: That’s a great question. I
believe many people think spherical
aberration probably doesn’t matter. But
we have to ask, now that we’re really
hitting our sphere and cylinder targets,
how can we further reduce the error in the
4
system? Since we know from Warren Hill’s
data that the best we’ll get on average is
about .18D from the target,1 how can we
remove the rest of the error in the system
to achieve better results, and ultimately,
happier patients? The answer is, we can
treat spherical aberration, and several
lens manufacturers are making lenses
to treat it. Using the OPD-Scan III, we’re
able to measure the corneal spherical
aberration, so we can choose the lens that
will get it as close to zero as possible.
When you address spherical
aberration, patients experience better
contrast sensitivity. Even if they have
some residual sphere and cylinder, they
can still be 20/20. That makes a surgeon’s
life easier.
etting ROI from
G
Wavefront
Dr. Patterson: How does wavefront
technology improve your return on
investment (ROI)?
Dr. Matossian: When I purchased my
OPD-Scan III, I set up a plan to create a
positive return on my investment. Every
one of my patients who is scheduled
for cataract surgery gets an advance
beneficiary notice (ABN). As I explain
to them, without the data from this
instrument, I can’t choose which lens is
best for them. Patients sign an ABN and
pay the charge for this service. The system
also helps pay for itself by increasing the
volume of discussions around premium
IOLs, which in turn helps me get more
word-of-mouth referrals.
Dr. Salz: The Marco unit also provides
exceptional autorefraction, and it does so
very quickly. Saving time makes money.
Dr. Noreika: That’s an important point.
A discussion of ROI should include the
revenue side and the expense side. Our
practices’ biggest line-item expense is staff,
so technology investments make sense if
they decrease labor costs. The OPD-Scan III
accomplishes this. There’s no need for a
highly skilled technician with a high level of
expertise to acquire the data, so that drives
up our ROI.
Dr. Jackson: We don’t need as many
technicians. I average two or three
more patients per hour with the EPIC
station and OPD-Scan III and need fewer
technicians. As Dr. Matossian mentioned,
our operational costs are increasing just
as our reimbursements are decreasing.
This type of new technology presents
a great way to help even out that
imbalance.
What’s more, this level of detail is
nearly equivalent to a “fingerprint” of the
eye. When you apply this technology to
your patients, in essence, every one of
them becomes a premium lens candidate.
ducating
E
Patients Visually
Dr. Patterson: Before we had wavefront
Dr. Jackson: A picture is worth a
thousand words. The OPD-Scan III
system integrates easily with our EHR,
which displays the pictures right in the
exam room. It minimizes chair time
and maximizes the true discussion
time. I show patients a picture and say,
“This is why I’ve chosen this advanced
lens implant technology for you.” They
understand immediately, so I can move
on to the next patient in less time.
Aligning Toric Lenses
Dr. Patterson: I want to discuss toric
IOLs since we’re using them more often.
How do you mark for your toric IOLs, and
does retroillumination help with that?
Dr. Solomon: We just talked about
Dr. Noreika: When I attended the AAO
meeting in 1979, there were no screens.
And when I implanted my first multifocal
lenses in 1991, those patients didn’t have
questions. The doctor knew best.
Fast forward to today, and I’ve got a
laptop, two large flat screens and a visual
acuity screen in my exam rooms. It’s not
enough that the data positions us to make
the best decisions in terms of outcomes
and expectations. Our “Boomer” patients
want to be part of the process. You’ve got
to show them. The more you show them on
the screen, the more they understand and
the happier they are with their outcomes.
Dr. Solomon: I think the flexibility of
the imagery is great. If a patient is savvy
enough to appreciate an axial map, that’s
wonderful, but I don’t see much of that in
how a great illustration makes it easier
for patients to understand their vision,
but quite honestly, clarity is better
for surgeons as well. By getting the
information from the OPD-Scan III
and using lenticular landmarks in the
retroilluminated image, we can triangulate
the steep axis based on those landmarks
to achieve an accurate representation
of the steep axis location very simply.
That gives us a great idea of how to align
the toric lens. In doing so, we reduce our
residual refractive cylinder by more than
50%. It’s such a remarkably easy way to
make that alignment, and the outcomes
speak for themselves.
We also can show patients how the
toric lens is placed using the marks and
alignment. The technology is wonderful for
the surgeon and impressive for the patient.
“... without the
data from this
instrument, I can’t
choose which lens
is best for them.”
•
technology, how did you educate your
patients about their needs and the potential
benefits of premium IOLs? And now that we
have wavefront technology, how has your
approach to patient education changed?
my practice. However, I can use the system
to show patients some really wonderful
illustrations of what their vision would
be if we didn’t address the higher-order
aberrations. They can see the distortion
that they could expect after surgery. This
finicky group of patients, with whom
we’ll be working for many years, wants
information. This is the best way to transfer
that knowledge.
— Cynthia Matossian, MD
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Luminary Insights
Enhanced Wavefront Refractions and Outcomes
Dr. Tyson: This is a must-have device if
you want optimal outcomes for toric IOLs.
It’s not just the preoperative marking and
alignment. We now have three different
toric lenses with three different spherical
aberration powers. We’re picking not only
where we’ll align the lens, but also which
spherical aberration is correct.
What I really like about the
OPD-Scan III is that after surgery, it can
show me if I achieved my intended target.
For example, if I implant a toric lens in a
small-pupil hyperope, I’m pulling the iris
back to check the marks and make sure
I aligned it properly. Postoperatively,
if I see a little residual cylinder, I don’t
know if the lens was placed properly,
or if it rotated, or if I just didn’t pick
up preoperative posterior corneal
cylinder. If the OPD-Scan III shows that
the corneal and lenticular cylinders are
perpendicular, then I know that I lined it
up correctly. This knowledge speeds up
my post-op visits for small pupils, and it
makes my job easier.
•
“ What I really like about
the OPD-Scan III is that
after surgery, it can
show me if I achieved
my intended target... If
the OPD-Scan III shows
that the corneal and
lenticular cylinders
are perpendicular,
then I know that I lined
it up correctly. This
knowledge speeds
up my post-op visits
for small pupils, and it
makes my job easier.”
— Larry Patterson, MD
Dr. Jackson: I can use the
retroillumination feature to show the
patient that his toric lens is aligned
exactly where I wanted it. There might
be a problem related to ocular surface
disease, the epiretinal membrane, or
posterior capsular opacification, but I can
show the patient it isn’t caused by the
cataract surgery or the location of the
lens implant.
Dr. Solomon: Often, patients say, “I
thought the cataract was on the surface
of the eye. You were going to peel it off.”
I can show them the retroilluminated
image and illustrate the surgery to them. I
can use features such as the point spread
function to demonstrate how a lens may
affect the outcome. This technology is a
phenomenal tool in the practice.
Dr. Tyson: The retroillumination image is
great for another reason. As a profession,
we’re being audited more frequently,
6
particularly for YAG capsulotomies. We
need proof that we’re performing YAG
capsulotomies on legitimate patients.
We have patients with good visual acuity
who are complaining to us, and we know
they’re seeing glare spots. It’s nice to have
the retroillumination image in the chart to
back us up during an audit.
electing a Wavefront
S
Approach
Dr. Patterson: How do you determine
whether to use standard LASIK ablation
profiles, wavefront-guided profiles or
wavefront-optimized profiles in your
LASIK patients? And how does pupil size
affect this decision?
Dr. Salz: If I have a patient with an 8-mm
pupil, I can show him a visual impression
of his current wavefront status. This leads
to a discussion of my recommendation,
whether it is wavefront-optimized or
wavefront-guided surgery. The choice
depends on the refraction, the pupil size
and other test scores.
Dr. Jackson: When we’re trying to decide
between performing a wavefrontoptimized or a wavefront-guided laser
ablation, we now have accurate data
on pupil size. We can put the whole
puzzle together — pupils, spherical
aberration and coma. The OPD-Scan III
provides all the diagnostic data we need
to make accurate decisions. We can
perform wavefront-optimized surface
ablation based on the patient’s spherical
aberration or coma, as well as perform
wavefront-guided surgery when it’s truly
needed.
Dr. Solomon: If you’re not bothering to
look at pupil size and do so accurately,
you’ll regularly fall short of your goals. We
might see a patient for a second opinion
after surgery who has zero refractive
error but can’t read as well as he would
like. We measure his pupils with the
OPD-Scan III and find that even under
photopic conditions, they don’t come
down below 3.6 mm — the size needed
for some multifocal lenses. If you get this
measurement before surgery, you find
the problem that went unnoticed in this
patient, and your patient is happy with
the outcome.
Considering Angle
Kappa
Dr. Patterson: Do any of you measure
angle kappa? If so, what role does angle
kappa play in your decision-making,
especially for multifocal IOLs?
Dr. Jackson: I presented a retrospective
Dr. Tyson: We can argue the benefit-torisk ratios for multifocal lenses, but I think
we all agree on the benefits of astigmatic
reduction in cataract surgery. If there’s a
measure of angle kappa, even with the toric
implant, there’s a degree of induced higherorder aberrations, coma in particular. But
when you have a patient sitting in one
chair getting multiple measurements,
you’ll gain a very good understanding
of the patient’s line of sight relative to
his pupil entry, or even to the vertex of
the cornea. This goes a long way toward
understanding higher-order aberrations
that would have gone unmeasured.
Dr. Patterson: A recent article1
indicates that 0.32μ of corneal coma
is the maximum allowed without
complications or the need to explant a
multifocal lens. Do you measure corneal
coma for multifocal IOL selection?
Dr. Jackson: Marc Michelson, MD,
conducted a very large study and found
that patients with high amounts of coma
and high total higher-order aberrations
were unhappy after surgery. 3 With the
data we need up front, we’re able to
prevent postoperative surprises for our
patients. We can choose the right lens
for each patient, whether we’re looking
at high angle kappa, coma, irregular
astigmatism or spherical aberration. We
can open up the premium IOL channel
in our practices and feel comfortable
that we’ll be able to provide an excellent
outcome because as the lens technology
has improved, so has our ability to predict
better outcomes and happier patients.
Dr. Tyson: I agree. With a real financial
crunch, if you’re not in the premium IOL
channel, your practice won’t survive. I’ve
aligned myself with this technology to be
more powerful than the ophthalmologist
next door. It finally gives us the comfort
level we need to be able to successfully
implement premium lenses. ■
REFERENCES
1. A
ly MG, Surgeons should consider coma
aberrations prior to multifocal IOL surgery. Ocular
Surgery News. March 31, 2011. Viewed online March
18,2014.
2. Jackson M, Effect of angle kappa on post-refractive
surgery IOL selection. XXX Congress of the
European Society of Cataract and Refractive
Surgeons (ESCRS), Milan, 2012.
3. Michelson MA, Myers RA. Corneal Higher Order
Aberrations and Visual Dysfunction With Multifocal
IOLs. Paper presented at: American Society of
Cataract & Refractive Surgery. 2012: Chicago.
“A s a profession,
we’re being audited
more frequently,
particularly for YAG
capsulotomies. We
need proof that
we’re performing
YAG capsulotomies
on legitimate
patients.…It’s
nice to have the
retroillumination
image in the chart
to back us up
during an audit.”
•
study of angle kappa at ESCRS. 2 We
looked at a subgroup of patients who
were unhappy after receiving multifocal
IOL implants with 20/20 outcomes.
We checked the ocular surface and
osmolarity, noted patients who had
YAG laser capsulotomy, and made sure
OCT scans were normal. These common
problems didn’t provide a reason for
dissatisfaction.
We did find that patients who had an
angle kappa greater than 0.4 mm typically
had more complaints of waxy vision or
night vision issues. As a result, when I
see patients preoperatively, one of the
first things I evaluate is angle kappa, and
I don’t use a multifocal lens if it’s greater
than 0.4 mm.
valuating Corneal
E
Coma
— Farrell “Toby” Tyson, MD
7
Power Forum 2 Symposium
November 15, 2013
Highlights from a live discussion held during
the 2013 meeting of the
American Academy of Ophthalmology
New Orleans, LA.
Scan to view the
complete video:
Power Forum 2
OPD-Scan III
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